Recurring concern

Unreliable recording and checking of placement risk information

First to latest report 14 Jul 2017 — 10 Oct 2025

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
10

What this concern includes

Includes failures in the dedicated placement-risk information process, including recording relevant risks, completing placement forms and referrals, checking or auditing their completeness and ensuring required information is available for placement decisions.

What is not included
  • Excludes generic documentation, audit or quality-assurance deficiencies not specifically tied to placement risk information.
  • Excludes failures in the substantive suitability of a placement where the placement-risk information process is not deficient.
  • Excludes unrelated referral, care-planning or safeguarding records unless they directly concern information required for a placement decision.

Reports and published responses 5 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Essex

    AI-generated summary

    Jillian Anne Steedman · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jillian Anne Steedman died at Pitsea Station on 12 May 2023 after intentionally going into the path of an oncoming train, following a deterioration in her mental health. The report identifies concerns including failures in information sharing, risk assessment, care planning, escalation, crisis response, and review of her placement and support arrangements.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Out-of-date information for aftercare planning, placement and risk assessment

    Wider context from the report

    “(11) The information for the aftercare planning and assessment presented for placement and risk for Mrs Steedman placed before the panel was significantly out of date. There was no review and the s117 care plan had not been updated since 13 September 2022. ”

    Source location

    Jillian Anne Steedman · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce structured handovers and shared care plans accessible to involved health, care-home and social-care professionals.

    Verbatim wording from the response

    “We have strengthened our governance by reviewing our information-sharing protocols with specific reference to how we work with professionals in other organisations. We have introduced structured communication methods for handovers and shared care plans which we have made accessible to all involved professionals including care home and social care staff. We are working in a more collaborative culture through regular multidisciplinary team meetings which is supporting our patient’s safety and planning. The Trust has relooked at its named”

    Source location

    Response from Essex Partnership University
    Page 1 · response
    Published 14 October 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Discuss professional curiosity with teams, remind staff to review care-home paperwork and consult carers, and provide support sessions on asking appropriate questions.

    Verbatim wording from the response

    “Response: We refer to our reply above under concern 4 in respect of care plans and risk assessments. In addition, as part of team reflections in this matter, the importance of professional curiosity was discussed and the team were reminded that they should review care home paperwork (where access is possible) and also speak with carers within the home. Support sessions were provided on asking right questions using professional curiosity and how this would have given more opportunity to understand Mrs Steedman’s needs and risks, whilst acknowledging that the Care Home may in turn approach the Trust with regards to any information or support required.”

    Source location

    Response from Essex Partnership University
    Page 3 · response
    Published 14 October 2025

    Open published response

  2. South Yorkshire (Western)

    AI-generated summary

    Marcia Grant · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Marcia Grant, a foster carer, died on 5 April 2023 after suffering significant chest injuries when a vehicle driven by her foster child collided with her. The report identified concerns about a shortage of placements, incomplete documentation and communication of risks, and inadequate risk assessment when placing the child with the Grant family.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to document relevant placement risks and complete required forms

    Wider context from the report

    “(2) Documentation and communication. Both the lack of documentation recording all the relevant risks, failure to complete forms and the lack of adequate communication of the risks in this matter led to a child being placed with a family where numerous individuals considered this was an inappropriate placement. Senior decision making was not based on all the appropriate information identifying there are inadequate systems and processes. ”

    Source location

    Marcia Grant · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use the correct, current placement referral form to share relevant information and risks with foster carers during matching discussions.

    Verbatim wording from the response

    “At the time of the initial placement being required for Child X, limited information was known about his background and needs. The initial placement referral form was brief and did not contain all relevant information. While the placement referral form was repeatedly updated over the short period Child X was in care with RMBC, we could not determine which placement referral form had been shared with Mrs Grant during the initial matching discussions due to the version control of documents. There were however a number of conversations with Mrs Grant about Child X. Mrs Grant had also taken steps to ensure that she knew where Child X was at all times and that she had locked away knives to ensure he could not access these. RMBC acknowledge that the storage and version control of documents required improvement and had already taken steps to address this.”

    Source location

    Response from Rotherham Metropolitan Borough Council
    Page 5 · response
    Published 5 September 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Require senior management approval and signed, child-filed placement referral forms before placements commence, with risks and relevant history shared beforehand.

    Verbatim wording from the response

    “Schemes of delegation and approval processes were also revised during 2023 to ensure that information about children requiring a placement is approved by a senior manager to ensure quality and consistency. Mitigation of risk and relevant history is considered and shared with prospective carers and providers prior to matching discussions taking place.”

    Source location

    Response from Rotherham Metropolitan Borough Council
    Page 5 · response
    Published 5 September 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update and revise children’s case-management forms through a dedicated monthly Systems User Group.

    Verbatim wording from the response

    “There have been challenges around pre-populated forms, within the children’s case management system, which RMBC acknowledge can be lengthy and cumbersome. Sections within certain forms were repetitive and led to social workers only completing relevant sections of forms, which leaves many sections blank. A dedicated Systems User Group within RMBC meets monthly to focus on work required to update and revise forms within the children’s case management system.”

    Source location

    Response from Rotherham Metropolitan Borough Council
    Page 6 · response
    Published 5 September 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Populate explicit risk-analysis sections in placement referral and matching approval documents for every child requiring a placement.

    Verbatim wording from the response

    “Following Mrs Grant’s tragic death, various specific changes have been made to ensure that the Council delivers the best possible services to foster carers and children and young people.”

    Source location

    Response from Rotherham Metropolitan Borough Council
    Page 6 · response
    Published 5 September 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Co-produce matching guidance with foster carers and continue improving documentation, recording and approval processes.

    Verbatim wording from the response

    “• Continue to make improvements to documentation, recording and approval processes and co-produce matching guidance with our foster carers”

    Source location

    Response from Rotherham Metropolitan Borough Council
    Page 7 · response
    Published 5 September 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Child X was not assessed as posing high risk, and no evidence indicated risks would increase to require a standalone assessment.

    Verbatim wording from the response

    “At the time of Child X’s placement, the Local Authority had worked on the premise that risks, when these are determined to be high, are considered within a more in-depth assessment. When placed, Child X was not deemed to pose a high risk of harm to himself, or others and no evidence was presented which indicated that the risks identified would increase and so a stand-alone risk assessment had not been completed. As acknowledged above, the initial placement referral form did not contain all the known risks about Child X. As concerns developed about the other young person in placement, this was considered and acted upon by RMBC, including the provision of a significant support package to help mitigate risk to him and an acceptance by the whole professional network that Child X’s placement could only be of very short duration.”

    Source location

    Response from Rotherham Metropolitan Borough Council
    Page 6 · response
    Published 5 September 2025

    Open published response

  3. Manchester South

    AI-generated summary

    Bernard Lyon · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Bernard Lyon, who had dysphagia and was living at Hyde Nursing Home, developed sepsis and aspiration pneumonia and died at Tameside General Hospital on 30 January 2024. The report describes concerns about the nursing home's management capacity, staffing and adherence to his modified diet plan, as well as multi-agency oversight, communication with families, ambulance handover delays and delays in administering antibiotics in a very busy emergency department.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a process to inform families about care home concerns and improvement plans

    Wider context from the report

    “4. The inquest was told that there was no process to let a family know of concerns that agencies had about a care home or that it was subject to an improvement plan. This meant that families were being left to make decisions about where to place family members unaware of the actual situation and concerns. ”

    Source location

    Bernard Lyon · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Explore greater transparency of care-home CQC action plans for families.

    Verbatim wording from the response

    “Your request found that there is currently no process in place for routinely communicating to families when a care home is subject to a CQC action plan. Action plans are documents which CQC ask a provider to produce when significant concerns are identified at a service. The action plan is produced by and is the responsibility of the provider – CQC receive it for awareness and monitoring purposes. Action plans can already be made publicly available, if requested through the provision of the Freedom of Information Act (FOIA). When CQC receive FOIA requests for action plans, they consider the public interest in disclosure on a case-by-case basis.”

    Source location

    Response from Department of Health and Social Care
    Page 4 · response
    Published 16 April 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise the Multi Agency Concern process to require providers to notify families about concerns in care homes.

    Verbatim wording from the response

    “We have revised our Multi Agency Concern (MAC) process to stipulate that providers are notifying families where there are concerns within the home. We will be launching the guidance with providers in the coming months, following sign off through our governance process. In the meantime, the MAC meetings stress the importance of notifying families where there are any concerns within homes that are subject to the MAC process.”

    Source location

    Response from Tameside Metropolitan Borough Council
    Page 1 · response
    Published 16 April 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Launch the revised Multi Agency Concern guidance with providers after governance sign-off.

    Verbatim wording from the response

    “We have revised our Multi Agency Concern (MAC) process to stipulate that providers are notifying families where there are concerns within the home. We will be launching the guidance with providers in the coming months, following sign off through our governance process. In the meantime, the MAC meetings stress the importance of notifying families where there are any concerns within homes that are subject to the MAC process.”

    Source location

    Response from Tameside Metropolitan Borough Council
    Page 1 · response
    Published 16 April 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The local authority may be better placed to address informing families about care-home concerns and improvement plans.

    Verbatim wording from the response

    “We have given careful consideration to this point and note that this report has also been sent to Tameside Metropolitan Borough Council who may be of greater assistance in addressing this aspect of your concerns. We note that Mr Lyon was receiving Continuing Healthcare Funding and therefore his partner was in contact with healthcare professionals who would be in a position to advise her about the suitability of any placement. Our reports are published on our websites and the report from our inspection in June 2023 made reference to the fact that the home was working towards an action plan.”

    Source location

    Response from CQC
    Page 5 · response
    Published 16 April 2025

    Open published response

  4. West London

    AI-generated summary

    Lance Scott Walker · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Lance Scott Walker, an 18-year-old looked-after child, was placed in unregulated accommodation in 2016, where another 18-year-old resident was later placed. Eleven days after they were placed together, the other resident fatally stabbed Lance in the afternoon of 15 August 2016. Concerns included the use and oversight of unregulated accommodation, inadequate assessment and communication of the other resident’s risks and needs, shortcomings in placement and provider due diligence, and failures in information-sharing and management.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate checking and auditing of placement forms and referral information

    Wider context from the report

    “3 Response from London Borough of Ealing The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals, with consideration on the introduction of mandatory fields for specific information to be included. The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry. ”

    Source location

    Lance Scott Walker · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  5. West Sussex

    AI-generated summary

    Steffan Bonnot · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Steffan Bonnot, a 17-year-old in the care of Brighton and Hove Local Authority, left a group during an outing on 1 January 2016 and was later found at a footcrossing after being struck by a train. The report states that he had anxiety about moving to a new foster placement and whether the prospective foster carers had been fully informed about his background. A principal concern was the lack of formal documentation showing exactly what information had been disclosed to the prospective foster carers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to document information disclosed to prospective carers

    Wider context from the report

    “1. The author of the serious case review reported that the prospective foster carers who were to offer a placement to Steffan had advised that they had not been made fully aware of all the background to Steffan’s case. This was, however, at odds with what Steffan’s Social worker told us. However there was no formal documentation detailing exactly what had been disclosed. It was not therefore possible to be clear what information the prospective Foster Carer had been given. As we know the failing to provide Foster Carers with all the background information was one of Steffan’s major concerns and added to his level of anxiety about his move. 2. The above concern would apply equally to any individuals entrusted with the care of a child. All relevant information should be made available and it should be documented as to what has been provided so that the carers can make an informed decision before any placement is agreed. The young person could then be confident as to what the prospective carer’s knew. ”

    Source location

    Steffan Bonnot · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026